A Review of Evidence on Method of Choice of Intestinal Anastomosis Dr Ho Nga Sze Caritas Medical Center

How to join them back?

Bowel Anastomosis Handsewn Stapled Compression ring device

Handsewn anastomosis First successful manual anastomosis in late 19th century Single layer vs double layer Continuous vs interrupted

Stapled anastomosis First introduced in 1908 Stapling device deploys and bend staples to secure tissue in place Range of choice of device for open and laparoscopic use, for different tissue thickness, circular or linear, cutting or non cutting

Compression ring device Sutureless anastomosis based on two opposing rings that trap the ends of transected bowel Subsequent ischemia and eventual sloughing of the trapped bowel, releasing the rings into the fecal stream Possible problem of foreign body retention

Which technique to choose?

Stapled versus handsewn methods for colorectal anastomosis surgery Neutzling CB. Cochrane Database Syst Rev. 2012. Systemic review comparing 9 RCTs Compared mortality, dishiscence, stricture, haemorrhage, reoperation, wound infection, procedure duration, hospital stay No statistical significant differences except Stricture was more frequent with stapling (P < 0.05) Time taken was longer with handsewn techniques Conclusion: No superiority of stapled over handsewn technique in colorectal anastomosis, regardless of the anastomotic level

Bowel anastomoses: The theory, the practice and the evidence base Goulder F. World J Gastrointest Surg 2012 September 27; 4(9): 208-213 Review on articles relating to small bowel, colonic and colorectal anastomotic technique from 1960 to 2010 Suggested either a stapled or sutured anastomosis is acceptable in most situations. Sutured or endoluminal circular stapled techniques are equally suitable for colorectal anastomoses (level 1a evidence), although the incidence of strictures is higher following stapled anastomoses.

Bowel anastomoses: The theory, the practice and the evidence base Goulder F. World J Gastrointest Surg 2012 September 27; 4(9): 208-213 A stapled side-to-side ileocolic anastomosis is preferable following a right hemicolectomy for cancer. (level 1a evidence) A stapled side-to-side anastomosis is likely preferable after an ileocolic resection for Crohn’s disease. (level 1b evidence) small bowel anastomoses should be sutured in the trauma patient (Level 3 evidence)

Systematic Review of the Technique of Colorectal Anastomosis Slieker J Systematic Review of the Technique of Colorectal Anastomosis  Slieker J.C, Daams F., Mulder I.M., et al. JAMA Surg. 2013;148(2):190-201. Review on 117 clinical and experimental articles in the past 4 decades Review of studies on: suture material, suture format (size of suture bites, in-between distance of bites, suture tension, configuration of the bite, and inverting vs everting sutures), single- vs double-layer colorectal anastomosis, interrupted vs continuous sutures, configuration of colorectal anastomosis (end-to-end, end-to-side, side- to-end, side-to-side, length of the side-limb, and length of the enterotomy), hand-sewn vs stapled colorectal anastomosis, hand-sewn vs compression colorectal anastomosis

Systematic Review of the Technique of Colorectal Anastomosis Slieker J Systematic Review of the Technique of Colorectal Anastomosis  Slieker J.C, Daams F., Mulder I.M., et al. JAMA Surg. 2013;148(2):190-201. Single-layer continuous suture technique by an inverting technique with slowly absorbable monofilament material seems preferable (level 1b evidence) Little evidence available for all aspects of hand- sewn colorectal anastomosis Dedicated, high-volume colorectal surgeon has a role in lowering the incidence of anastomotic leak

Systematic Review of the Technique of Colorectal Anastomosis Slieker J Systematic Review of the Technique of Colorectal Anastomosis  Slieker J.C, Daams F., Mulder I.M., et al. JAMA Surg. 2013;148(2):190-201. Stapling and hand-sewn anastomoses give equal leakage rate (level 1a evidence) Compression and hand-sewn colorectal anastomosis have similar leakage rates (level 1b evidence)

Compression anastomosis ring device in colorectal anastomosis: a review of 1,180 patients Masoomi H, Luo R, Mills S, Carmichael J.C. Senagore A.J, et al. The American Journal of Surgery (2013) 205, 447-451. Retrospective study on outcome of 1180 patients underwent elective laparoscopic or open left sided colectomy using compression device (ColonRing) between 2008-2010 Data from NiTi Surgical Solutions database

Compression anastomosis ring device in colorectal anastomosis: a review of 1,180 patients Masoomi H, Luo R, Mills S, Carmichael J.C. Senagore A.J, et al. The American Journal of Surgery (2013) 205, 447-451. The overall anastomotic leak rate was 3.22% (38 patients), within the expected rate of 3-5%. Leak rate is lower in left sided colectomy (3.79% ) than in anterior resection (1.93%) The median ring expulsion time was 8 days. The ring did not expel in one patient. Concluded that ColonRing is a feasible and safe alternative for end-to-end colorectal anastomosis.

In summary… No superiority of stapled over handsewn technique in colorectal anastomosis, regardless of the anastomotic level Either stapled or sutured techniques are suitable in most situations Specific situations: Right hemicolectomy for cancer: stapled side-to-side ileocolic anastomosis Ileocolic resection for Crohn’s disease : stapled side- to-side anastomosis is likely preferable Handsewn preferred in small bowel resection following trauma

In summary… Evidence on detail aspects of handsewn anastomotic technique is lacking. Single-layer continuous suture technique, by an inverting manner, with slowly absorbable monofilament material seems preferable for colorectal anastomosis. Compression and hand-sewn colorectal anastomosis have similar leakage rates More study on compression device warranted

What should we choose? Meticulous technique Good blood supply Patient and disease factor Surgeon’s experience and preference Equipment availability Meticulous technique Good blood supply No tension

Reference Bailey and Love's Short Practice of Surgery 26th ed Goulder F. Bowel anastomoses: The theory, the practice and the evidence base. World J Gastrointest Surg 2012 September 27; 4(9): 208-213 Löffler T, Rossion I, Gooßen K, et al. Hand suture versus stapler for closure of loop ileostomy--a systematic review and meta-analysis of randomized controlled trials. Langenbecks Arch Surg. 2015 Feb;400(2):193-205. Masoomi H, Luo R, Mills S, Carmichael J.C. Senagore A.J, et al. Compression anastomosis ring device in colorectal anastomosis: a review of 1,180 patients. The American Journal of Surgery (2013) 205, 447-451. Mooloughi S, Joudi M, Dalili AM, Dalili A. Different types of anastomotic methods: a review of literature . Rev Clin Med. 2015;2(4):178-181. Slieker J.C, Daams F., Mulder I.M., et al . Systematic Review of the Technique of Colorectal Anastomosis. JAMA Surg. 2013;148(2):190-201 Zollinger, R.M.,  Ellison, E.C. 2011. Zollinger Atlas of Surgical Operation 9th Ed.

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